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Once the location and mechanism of stenosis have been identified 50 mg voveran visa muscle relaxant images, the severity of obstruction may be assessed discount 50mg voveran mastercard muscle relaxant pictures. While Doppler imaging is crucial for this purpose cheap 50 mg voveran with amex gastrointestinal spasms, the importance of careful two-dimensional imaging must also be stressed order 50 mg voveran with mastercard muscle relaxant elderly. While Doppler gradients often provide accurate estimates of disease severity, there are some instances in which Doppler findings may underestimate the degree of stenosis. Decreased cardiac output, multiple levels of obstruction, or the presence of a “pop-off” (atrial or ventricular septal defect, patent ductus arteriosus, etc. Absent any of these scenarios, however, spectral Doppler can provide a highly accurate assessment of the severity of discrete left ventricular outflow tract obstruction. An apical long-axis view often provides optimal alignment for Doppler interrogation of the left ventricular outflow tract, while a high right parasternal view may also be useful in assessing the Doppler gradient (164). Doppler imaging will also provide accurate information on the presence and severity of aortic insufficiency. Doppler assessment of aortic valve stenosis, including valve area calculation using the continuity equation, is covered in detail in Chapter 13 and will not be discussed at length here. One key point to reiterate is the difference between the peak-to-peak gradients obtained by direct pressure measurement in the cardiac catheterization laboratory and the peak instantaneous pressure gradient obtained by spectral Doppler. As discussed in Chapter 13, these two measurements reflect different physiologic parameters, and the peak instantaneous gradient is generally P. While the mean Doppler-derived gradient may more closely approximate the peak-to-peak gradient than the peak instantaneous gradient does (167), the best estimate of the catheter-derived gradient is likely obtained by correcting the peak instantaneous gradient for the phenomenon of pressure recovery. Pressure recovery refers to an increase in fluid pressure that occurs after the immediate drop in pressure associated with passing through an area of discrete stenosis (168). Pressure recovery may be amplified in pediatric patients with small aortae, and a study of pediatric patients with simultaneous catheter and Doppler-based assessments of aortic valve gradients demonstrated that correcting peak instantaneous gradient for pressure recovery, using a previously validated formula, resulted in the best approximation of peak-to-peak gradient (169). The primary purpose in attempting to correlate Doppler estimates of gradient with peak-to-peak gradients obtained in the catheterization laboratory is to aid in clinical decision making, as the traditional indications for intervention have been based on catheter-derived numbers. In these guidelines, severe stenosis is defined by a peak velocity across the aortic valve of ≥4. In the setting of an artificially low gradient due to decreased cardiac output, an 2 2 2 aortic valve area ≤1. With time, noninvasive Doppler assessment of the degree of stenosis may increasingly replace catheter-based evaluation in clinical practice. Additional roles for echocardiography in the assessment of aortic stenosis include the evaluation of left ventricular systolic and diastolic function (discussed in detail in Chapter 13). The degree to which a left ventricle is able to accommodate increased afterload without undergoing pathologic remodeling is highly variable, and the sensitivity of echocardiography, particularly using newer strain-based assessments, in identifying subtle systolic and diastolic dysfunction is crucial in optimal clinical decision making (172,173,174). Given the high incidence of additional cardiac anomalies in patients with left ventricular outflow tract obstruction, a complete and careful anatomic survey is essential. In infants with critical aortic stenosis in whom a decision regarding a one versus two ventricle repair must be made, accurate measurements of all left heart structures, as well as detailed assessment of the mitral valve and its apparatus, is crucial. Three-dimensional transthoracic echocardiography may provide useful anatomic information when used in conjunction with standard two-dimensional echo and is particularly useful in delineating the mechanism of complex subaortic obstruction (163). Late gadolinium enhancement as a marker for fibrosis is an independent predictor of mortality in adults with aortic stenosis (176), although the same prognostic value has not yet been shown in children. The primary role for exercise testing in the contemporary evaluation of aortic stenosis is in the risk stratification of asymptomatic patients with severe disease. The same guidelines recommend avoiding exercise testing in any symptomatic patient. Patients who develop symptoms with exercise are considered symptomatic, despite the lack of symptoms at baseline, and aortic valve intervention is recommended. Cardiac Catheterization Although cardiac catheterization is still considered the gold standard to measure pressure gradients and determine the need for intervention, it has largely been replaced by echocardiography and other noninvasive imaging modalities as a diagnostic tool for aortic stenosis. More typically, cardiac catheterization is undertaken as a therapeutic tool for patients with valvar aortic stenosis (see “Therapeutic Cardiac Catheterization” below). That said, cardiac catheterization continues to have an important role in the diagnosis of aortic stenosis by providing hemodynamic assessment of disease severity and defining the anatomic substrate for obstruction. This can be especially useful when echocardiographic images are inadequate or result in conflicting data. When performing a cardiac catheterization for the diagnosis of aortic stenosis or assessment of disease severity, it is generally optimal to perform the procedure using light conscious sedation to mimic resting hemodynamic conditions as closely as possible. General anesthesia can alter systemic vascular resistance, which can impact measured pressure gradients. In addition, most measurements should be performed prior to administration of iodinated contrast, as this can cause elevations in the systolic and end-diastolic blood pressure. Typically, left heart catheterization from a retrograde approach allows direct measurements of left ventricular outflow tract obstruction via catheter pullback pressure recordings. Alternatively, a transseptal approach can allow simultaneous measurement of left ventricular and aortic pressure. While several catheter types can be used to measure pressure gradients, use of an end-hole catheter generally permits differentiation P. Importantly, pressure gradients can be underestimated in low cardiac output states or in situations where the left ventricle is not “preloaded” with a full cardiac output. For example, in infants with critical aortic stenosis, any measured gradient across the aortic valve does not reflect the true degree of outflow tract obstruction because the left ventricular function is impaired and often an atrial septal defect allows egress of pulmonary venous blood to the right heart with maintenance of cardiac output via a patent ductus arteriosus. In addition to determining pressure gradients, catheter assessment of cardiac output, via the Fick principle or thermodilution technique, as well as measurement of the left ventricular end-diastolic pressure can also be performed and can be helpful in determining disease severity or tracking progression. For both subvalvar and supravalvar stenosis, slow pullback with an end-hole catheter is necessary to obtain these tracings, but distinguishing the site of obstruction may not be possible if the level of stenosis is very close to the aortic valve. Use of angiography can also delineate whether aortic stenosis is subvalvar, valvar, or supravalvar (Fig. In the case of subvalvar stenosis, a left ventriculogram can help define the morphologic substrate (discrete subaortic membrane versus tunnel-like obstruction) and can also assess ventricular function and degree of left ventricular hypertrophy. It can also delineate aortic root measurements to assess for the presence of aortic root ectasia commonly observed in patients with valvar aortic stenosis. Notably, because various levels of aortic stenosis can coexist in the same patient, multiple angiograms are typically necessary. A: In this patient with valvar aortic stenosis, a pigtail catheter is positioned retrograde into the ascending aorta. Contrast injection reveals a doming aortic valve with a narrow effective orifice, seen via the negative contrast washout from anterograde flow of noncontrast blood across the aortic valve (indicated with an asterisk). This aortic valve is bicuspid (best visualized on a lateral projection, which is not shown). The aortic valve annulus can be measured (dotted line) and is used to determine balloon size for balloon aortic valvuloplasty. B: In a patient with subvalvar aortic stenosis, a catheter is positioned retrograde into the left ventricle. With contrast injection, there is a discrete subaortic membrane (marked with an asterisk) visible below the level of the aortic valve (arrow) in the left ventricular outflow tract. C, D: In this patient with Shone complex, injection of contrast through a pigtail catheter positioned in the aortic root reveals supravalvar aortic stenosis with narrowing at the sinotubular junction (arrow; best seen in the anteroposterior projection (C)).
It must be noted that in adults bone modeling is virtually absent otherwise purchase voveran on line amex spasms gerd, and the new bone formation exclusively depends upon bone remodeling voveran 50 mg online spasms from alcohol. Anabolic window can simply be deﬁned as a period in which bone formation exceeds bone resorption buy 50 mg voveran amex knee spasms at night. This concept is exploited in the management of osteoporosis by using teriparatide purchase voveran 50 mg overnight delivery muscle relaxant pills. This window period usually lasts for 12–18 months, as both bone formation and resorption decline after this period. However, the area under curve for this anabolic window can be “expanded” by the use of bisphosphonates along with teripara- tide, thereby resulting in increased new bone formation due to suppression of bone resorption. The use of teriparatide is associated with an “anabolic window” and bisphospho- nates lead to an “expanded anabolic window” by suppression of osteoclast activity. Some studies suggest a beneﬁcial effect of combined therapy in patients with osteoporosis, while others do not support this notion. Therefore, the combined use of bisphosphonates and teriparatide is not routinely recommended. What are the differences between teriparatide and bisphosphonate in the management of osteoporosis? The differences between teriparatide and bisphosphonate in the management of osteoporosis are summarized in the table given below. A 72-year-old postmenopausal female was incidentally detected to have osteopenia (T-score −2. Guidelines recommend estimation of 10 year probability of fracture risk in individuals with osteopenia. A 65-year-old postmenopausal female was incidentally detected to have osteoporosis (T-score−2. She had received yearly zoledronic acid for the past 3 years and did not have any fragility fracture. The long-term use of bisphosphonates is associated with atypical fractures and osteonecrosis of jaw, due to severe suppression of bone turnover. In addition, bisphosphonates have a prolonged tissue half-life which exceeds more than 10 years. Further, use of bisphosphonates beyond 5 years is beneﬁcial only in those with high risk of fracture. Hence, a patient with no new fragility fracture or low risk of fracture may be given a “drug holiday,” after 3–5 years of their use. In the index case, as there was no history of fragility fracture, she was given a drug holiday. The patient who is given a drug holiday should be kept under regular surveillance for deterioration in bone mineral density and/or bone turnover markers every 1–2 years, if previously received alendronate and 2–3 years for zoledronic acid. The fracture sites are atypical as compared to osteoporotic fractures and include shaft of femur, pubic bone, and ischium; sites which are predominantly com- posed of cortical bone. The radiological hallmarks include thickened cortices and transverse orientation of fracture line. Delayed healing of fracture despite adequate orthopedic management sug- gest the presence of underlying metabolic bone disease. This may be due to defective bone collagen (osteogenesis imperfecta) , impaired bone remodeling (primary hyperparathyroidism), and poor mineralization (osteomalacia). Physical activity should be encouraged and compliance to treatment including adequate amount of calcium and vitamin D intake must be ensured. The clini- cal, biochemical, and radiological parameters to be monitored on follow-up are summarized in the table given below. Stable or increase in bone mineral density should be considered as a beneﬁcial response to treatment. What should be done if there is no signiﬁcant improvement in bone min- eral density in a patient with osteoporosis on pharmacotherapy? Hypocalcemia; dermatological manifestations like eczema, cellulitis, and erysipelas; and possibly increased risk of serious infections are the adverse events associated with deno- sumab. The unique features of denosumab as compared to bisphosphonates include subcutaneous administration at a frequency of 6 months, lack of gastroin- testinal adverse events, safety in renal failure, and rapid reversibility of its action, because it is not accumulated into bone tissue. The quick reversibility of its effect can be a disadvantage if patient misses a dose. There are few reports of osteone- crosis of jaw and atypical fractures with the use of denosumab. Unlike bisphos- phonates and denosumab, odanacatib does not affect osteoclast survival; rather, it only inhibits osteoclast function. Nonspeciﬁc cathepsin inhibitors are associated with scleroderma-like skin thickening and rashes, which have not been reported with odanacatib, as cathep- sin K is bone speciﬁc. Anti-sclerostin antibody (romosozumab) is an effective anabolic agent which promotes new bone formation by facilitating Wnt pathway. It is administered subcutaneously monthly or every 3 months and is associated with minimal adverse events, e. Tyrosine Src kinase plays an important role in osteoclast activation and conse- quent bone resorption. Like odanacatib, it only impairs osteoclast function and does not lead to osteoclast apoptosis. The drug is currently explored for osteosarcoma and in skeletal metastasis, rather than osteoporosis. This occurs because of slow pro- gression of immuno-inﬂammatory destruction of β-cells. They are predis- posed for other autoimmune disorders and may have familial clustering of diabe- tes. The following criteria have been proposed for the diagnosis of fulminant type 1 diabetes • Ketosis or ketoacidosis within a week after onset of hyperglycemic symptoms • Plasma glucose level ≥288 mg/dl and HbA1c<8. Treatment includes intravenous saline and insulin during ketoacidosis followed by basal-bolus insulin after recovery from ketoacidosis. In 16 Type 1 Diabetes Mellitus 367 addition, the infants are exclusively breast-fed till the age of 6 months, which minimizes the exposure to environmental antigens. Therefore, occurrence of diabetes before the age of 6 months suggests the possibility of neonatal diabetes. These patients typically present within ﬁrst few days to weeks of life, and the disease commonly remits by 12 weeks of age. However, 50% of these patients may have a relapse of disease during adolescence or young adult- hood. However, glucotoxicity has been proposed as a possible mechanism for rapid decline in β-cell function, which improves after treatment with insulin. The environmental factors that predispose to type 1 diabetes include viral infections (congenital rubella, coxsackie virus, and mumps), dietary factors (bovine milk and gliadin), and toxins (nitrates). Coxsackie virus speciﬁcally affects β-cells in genetically predisposed individuals, and consequently results in insulitis. This may be partially attributed to increase in personal hygiene (“hygiene hypothesis”) and rising incidence of obesity (“accelerator hypothesis”).
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This will reduce the risk of con- fusing information about two different patients with the same or similar names voveran 50mg mastercard spasms from overdosing. A Qm program must evaluate the production of test results across the entire performance spectrum: the preanalytic stage cheap voveran line knee spasms causes, the analytic stage best order voveran muscle relaxant benzodiazepine, and the post- analytic stage order voveran with visa muscle relaxant football commercial. The clinical leadership is responsible for identify- ing specifc performance indicators to monitor against defned performance thresholds. Generally, tests are selected for monitoring based on the potential impact to patient care. Performance indicators should include appropriate activities across the preanalytic, analytic, or postanalytic phases. In this setting, it is necessary to understand the industry standards established in the commercial marketplace such as acceptable wait times for patients in an outpatient phlebotomy service. It is often necessary to conduct sev- eral observations and measure the time to complete the pro- cedure from start to fnish. Generally, an acceptable performance threshold is reported as the ability of the laboratory to complete the procedure and meet the performance standard with a high rate of success. A poorly defned performance threshold or inadequate data collection will lead to a failure to identify problems with the procedure, and thereby pose an undue risk to patient care. The actual perfor- mance can then be compared to the threshold and evalu- ated as to whether the actual performance is acceptable or unacceptable. An appropriate performance threshold must be defned for the performance indicator. Therefore, it is necessary to understand the unique characteristics that are associated with a particular test or procedure. The leadership is responsible for acquiring resources and managing expenses in both the operating and capital budgets. It is also necessary to manage the revenue stream so that billing claims are submitted correctly and timely to maximize payment for services. When assessing the expansion of an existing laboratory service or implementation of new test pro- grams, the fnancial impact of the operating costs (if necessary, capital expenses as well) must be calculated. The opportunity cost of not choosing to pursue new or expanded programs must be assessed. A fnancial assessment should also consider the pros and cons of “make versus buy” and determine whether it is cheaper and more effcient to “make” the test in the laboratory or “buy” it from a vendor. It is important to engage staff so that they can contrib- ute to controlling supply expense. Defned processes for inventory manage- ment should be structured to minimize unnecessary overstocking on supplies. The timeliness of claim submissions should be monitored as well to minimize the risk of nonpayment for services rendered. Excessive supply inven- tory ties up fnancial resources that could be better spent on salaries, capital equipment purchase, new or expanded programs, and infrastructure needs. The management team must routinely review actual expenses that are charged to the operating budget. Although much of the purchasing and accounts payable functions are electronically processed, there are still opportunities for error. This situation also warrants a review to determine that insurers will reimburse payment for the new use of the test. This report can indicate problems that require the manager to investigate and take action to ensure that payments are received. Upon initial examination, a test may have a modest fnancial impact on the laboratory budget. However, the results may allow pro- viders to initiate treatment so that it substantially benefts both patient care and the institution’s fnancial picture. In addition, all labora- tory staff must participate in effectively managing supplies to better control operating expenses. For every dollar in operating cash spent on supplies, one dollar less is available for salaries and capital equipment. Generally, payment for testing services is not received until 45 days or longer after the service has been performed. Thus, there is little beneft to investing operating cash to purchase a product that could last for many months or years. This includes verifying that all lease payments or reagent rental fees are correct, as per the contracts. For those supplies that are provided to clients, there should be a reasonable association between the test volumes returned to the laboratory with supply items delivered to the client. When implementing new test programs it may be necessary to confrm that insurers will provide reimbursement for a new service. This will ensure that claims are consistently and correctly submitted within contractual requirements. The manager is responsible for taking corrective action to ensure that claims are accurate, complete, and meet con- tractual deadlines. There may be circumstances when incurring additional costs to provide a laboratory service is more than offset by an enhanced outcome for patient care. A well-defned training program is necessary to ensure consistent performance by all new employees. It is necessary to interview candidates and thoroughly assess their capabilities to meet the job requirements. However, it is equally important to evaluate the candidate’s interpersonal communication skills with other employees and to obtain objective references from the candidate’s current and previ- ous employers. It also enables coworkers to form a stronger sense of team since their work is measured based on objective standards and not subjective perception. A competitive salary is one of the key elements for attract- ing and retaining employees. Laboratory management must identify those circumstances that can create a noncompeti- tive position with salaries. It is also important to engage the human resources staff to assist with collecting data and, if necessary, fnding solutions. This allows the laboratory to continue to meet performance standards and minimize any disruption in service. When possible, candidates should be interviewed by colleagues and subordinates as well as by superiors. This allows employ- ees to understand what is expected and enables the laboratory to dependably support patient care. The human resources staff can provide the necessary data to justify appropriate actions to recruit and retain staff. When appropriate, analyze data and defne when staffng coverage should be assigned. In addition to implement- ing procedures, the staff must be educated to properly perform safety procedures and comply with them. In the laboratory, all staff are required to wear laboratory coats and gloves when handling specimens and performing tests. Laboratory management must have defned written procedures for laboratory safety and must monitor compli- ance with these procedures.
Damage to the nasolacri- mal duct is less likely with the traditional technique than the swing-door technique as there is less utilization of the backbiter and therefore less risk to the nasolacrimal duct buy 50mg voveran muscle relaxant. If the nasolacrimal duct is opened buy voveran now zyprexa spasms, any small bony pieces are removed and the opening left as it is order voveran 50 mg with mastercard spasms near liver. A crush injury of the duct has a worse prognosis as this may result in scar tissue formation within the duct with subsequent ob- struction of the duct order 50mg voveran amex muscle relaxant new zealand. The surgeon should also be aware that collapse of the uncinate onto the lamina papyracea (so-called atelectatic uncinate) puts the orbit at greater risk of damage. Anterior incisions into an atelectatic and will usually make the incision into the uncinate as indicated by uncinate will result in a high incidence of orbital penetra- the A arrow as this gives a margin of safety when compared with the incision in the region of the B arrow which may traverse the lamina tion and should not be used. On clinical examination the presence of a posterior fontanelle and circular fow of mucus should be sought. If a posterior fontanelle ostium or accessory ostium is iden- tifed, this should be surgically joined to the natural ostium to prevent ongoing circular fow of mucus. This can be done by inserting a backbiter into the accessory ostium and coming forward to the natural ostium. After creating this tissue edge, the microdebrider is used to trim away excessive tissue. The uncinate is plastered against the lamina papyracea over a considerable length. Currently there is debate as to whether enlarging the maxillary sinus ostium can be detrimental to the long-term health of the sinus. In addition, failure of the surgeon to9 defense of the nasal sinus mucosa by stimulating ciliary motil- ity and by inhibiting infection by bacteria, viruses, and fungi. Recently there have been contrary opinions expressed into the posterior fontanelle ostium with resultant recurrent where surgeons have argued that the proximity of the unci- chronic sinusitis symptoms (Fig. An additional consequence of removal of the posterior fontanelle during enlargement of the maxillary ostium may be dumping of secretions from the frontal sinuses and ante- rior ethmoids into the maxillary sinus. The natural drainage pathway of the frontal sinus and anterior ethmoids is above the natural ostium of the maxillary sinus along the base of the bulla ethmoidalis before crossing the posterior fonta- nelle and under the eustachian tube to the nasopharynx. Currently the decision as to whether the maxillary ostium is enlarged or not is dependent on the degree of disease within the maxillary sinus. If the surgeon wishes to view the maxillary sinus then the ostium is enlarged until the dimensions are 10 mm by Fig. After removal of the horizontal bone of the uncinate, antrostomy on the left side. In most cases this is sufcient to view the majority of the maxillary sinus with a 70-degree telescope. If there is submucosal abscess formation or polyps and mucus that 36 Endoscopic Sinus Surgery Fig. In patients with Samter’s triad and cystic fbro- sis the ostium is always enlarged to its maximum size. This need removal from the sinus, curved instruments and mal- allows maximal penetration of nasal douching usually with leable suctions are used through this natural but enlarged topical medication into the maxillary sinus. If, however, the sinus has grade 3 disease where there wall of the maxillary sinus can usually be removed through an is extensive polyp formation within the maxillary sinus or enlarged maxillary ostium. If the majority of polyps or mucin large amounts of thick and viscid secretions, particularly remain after attempted removal through the large ostium, then fungal mucin, a canine fossa trephine is performed and the a canine fossa trephine is performed as described later. The diagnosis can only be confrmed, however, on endos- copy during surgery as the opacifcation may well be mucus which is easily cleared through the natural maxillary ostium. The frst step at surgery is to perform an uncinectomy and middle meatal antrostomy. A 70-degree endoscope is used to visualize the natural ostium and contents of the maxillary sinus. The extent of disease afecting the maxillary sinus should be graded according to Table 5. The researcher at that stage was polyps and mucus from the posterior region of the maxillary not aware what surgical procedures had been performed or sinus can be removed with angled microdebrider blades and what the current status of the patient sinuses were. The surgical notes microdebrider blades and instruments have when passed were reviewed and the patients were placed into two groups through the maxillary antrostomy or inferior meatal antros- depending on whether the patient had undergone a large tomy, polyps in the anterior, inferior, and medial regions middle meatal antrostomy with clearance of all accessible cannot be reached. If the blade or instrument is passed or puncture was performed our standard practice is to place through the anterior wall of the maxillary sinus it only has a microdebrider blade through this puncture/trephine site one fulcrum so a much greater degree of manipulation of the and perform a complete clearance of polyps under visualiza- blade is possible (Fig. Only the polyp was taken while the base layer and aggressive sinus disease such as allergic fungal sinusitis, of mucosa underlying was preserved. This grading was confrmed on nasal endos- as Samter’s triad and severe recurrent polyposis, it appears copy. In addition the patients were asked to grade their sinus that if the maxillary sinus is left flled with polyps that these symptoms on a visual analogue scale and to complete the polyps do not resolve with only a maxillary antrostomy. If the overall disease burden 5 Uncinectomy and Middle Meatal Antrostomy 39 A B C D Fig. The single fulcrum of the canine fossa puncture broken white arrow) and the posterior fulcrum (inferior meatal antros- is indicated (white arrow) (B,C,D), illustrating how the entire maxillary tomy, white arrow). The region of the maxillary sinus that can be cleared sinus can be accessed as the blade only has a single fulcrum. This helps remove most of the blood other sinuses were treated in exactly the same manner with from within the sinus and allows the blade to be visualized complete removal of all polyps and mucin from these sinuses within the sinus (Fig. This visualization en- confrmed the clinical perception that complete clearance of sures that the blade is within the sinus and not in the orbit the severely diseased maxillary sinus plays a major role in or soft tissues. If the symptoms associated with the soft tissue dissection were The old standard technique for canine fossa puncture was as removed, 28% of patients experienced a persistent signifcant follows21: the lip of the patient was elevated and the canine complication of facial tingling, numbness, or continued pain. The root of this tooth was the upper lip and/or the upper teeth was seen in up to 38% traced with the fnger under the lip until the canine fossa was of patients. One milliliter of 1:80 000 2% lidocaine and adrena- to be a result of injury to branches of the infraorbital nerve. When the bone was too thick, a couple of verse the anterior maxilla and supply sensation to the upper frm taps with the palm of the hand was usually sufcient lip and teeth. Placement of the trocar through the anterior to drive the trocar through the bone. However, in some pa- wall of the maxilla can injure these nerves and result in par- tients in whom the bone was thicker, the trocar needed to esthesia and numbness of the upper lip and teeth. After the tip of the trocar was felt injury to this nerve increases if the trocar is placed too medi- to fully penetrate the sinus, it was withdrawn and the mi- ally and cranially. The middle superior alveolar nerve is seen in 23% of patients and may have no branches (10%) or multiple branches (13%; type 7) as seen in (D). One of the problems associated with canine fossa puncture is that the trocar is placed in a blinded manner. Although the soft tissue is dissected of the anterior face of the maxilla, the the risk of possible associated neurologic injury. When a 4-mm debrider blade is placed through placement of the trocar may cause fracture of the thin bone this opening the ft is very snug and when the blade is manip- of the anterior wall of the maxilla around the puncture site. If signifcant pressure is applied to an endoscope sheath* was developed with an extension to the trocar a fracture of the surrounding bone will often occur. This enlarges the area of trauma and in so doing increases 24 Technique (Videos 8 and 9) An 6-mm incision is made in the gingivobuccal sulcus above and slightly lateral to the apex of the canine tooth.